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<body>
<table width="909" height="875" border="0" cellpadding="0" cellspacing="3" align="center">
  <tr>
    <td height="27" colspan="5" bgcolor="#95D706">&nbsp;</td>
  </tr>
  <tr>
    <td height="207" colspan="5" valign="top">
    <form id="form2" name="form2" action="">
      <label for="allId"></label>
      <table width="906" height="207" border="0" cellpadding="0" cellspacing="0">
        <tr>
          <td width="276" height="207" valign="top"><table width="265" height="207" border="0" cellpadding="0" cellspacing="3">
            <tr>
              <td width="52" height="24" align="center" bgcolor="#CCCCCC" id="form3">HN :</td>
              <td width="204" bgcolor="#E2E2E2">&nbsp;</td>
              </tr>
            <tr>
              <td height="146" colspan="2" valign="top"><table width="270" height="146" border="0" cellpadding="0" cellspacing="0">
                <tr>
                  <td width="270" valign="top" bgcolor="#FFCCCC">&nbsp;</td>
                  </tr>
                </table></td>
              </tr>
            <tr>
              <td height="25" align="center" bgcolor="#FF6633" id="form3">All :</td>
              <td bgcolor="#E2E2E2">&nbsp;</td>
              </tr>
            </table></td>
          <td width="384" valign="top"><table width="384" height="206" border="0" cellpadding="0" cellspacing="3">
            <tr>
              <td colspan="3" align="left" bgcolor="#CCCCCC" id="form3">INDICATION</td>
              </tr>
            <tr>
              <td colspan="2" bgcolor="#E2E2E2">&nbsp;</td>
              <td width="48" align="center" bgcolor="#999999"><strong>...</strong></td>
            </tr>
            <tr>
              <td colspan="3" bgcolor="#E2E2E2">&nbsp;</td>
              </tr>
            <tr>
              <td width="123" bgcolor="#CCCCCC" id="form3">INR Target</td>
              <td width="201" bgcolor="#E2E2E2">&nbsp;</td>
              <td align="center" bgcolor="#999999"><strong>...</strong></td>
            </tr>
            <tr>
              <td bgcolor="#CCCCCC" id="form3">Thrombotic risk</td>
              <td bgcolor="#E2E2E2">&nbsp;</td>
              <td align="center" bgcolor="#999999"><strong>...</strong></td>
            </tr>
            <tr>
              <td bgcolor="#CCCCCC" id="form3">Bleeding risk</td>
              <td bgcolor="#E2E2E2">&nbsp;</td>
              <td align="center" bgcolor="#999999"><strong>...</strong></td>
            </tr>
          </table></td>
          <td width="246" valign="top"><table width="247" height="206" border="0" cellpadding="0" cellspacing="3">
            <tr>
              <td height="27" bgcolor="#CCCCCC" id="form3">Underlying disease </td>
            </tr>
            <tr>
              <td height="27" bgcolor="#E2E2E2">&nbsp;</td>
            </tr>
            <tr>
              <td bgcolor="#FF3333">&nbsp;</td>
            </tr>
          </table></td>
        </tr>
        </table>
    </form></td>
  </tr>
  <tr>
    <td width="213" height="629" valign="top">
    <table width="209" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="209" height="629" valign="top" bgcolor="#E2E2E2">
        	<jsp:include page="/jsp/template/menu.jsp" />
        </td>
      </tr>
    </table></td>
    <td width="690" colspan="3" valign="top"><form id="form1" name="form1" method="post" action="">
        <label for="hnId4"></label>
        <table width="694" height="36" border="0" cellpadding="0" cellspacing="1">
          <tr>
            <td width="692" bgcolor="#5B8E0B">&nbsp;</td>
          </tr>
        </table>
        <table width="688" height="587" border="0" cellpadding="0" cellspacing="8">
          <tr>
            <td width="370" height="571" align="right" valign="top"><table width="375" height="32" border="0" cellpadding="0" cellspacing="2">
              <tr>
                <td width="100" bgcolor="#CCCCCC">วันที่มา</td>
                <td width="269" bgcolor="#E2E2E2">&nbsp;</td>
              </tr>
            </table>
              <table width="375" border="0" cellspacing="2" cellpadding="0">
                <tr>
                  <td width="100" bgcolor="#CCCCCC">ประเภทผู้ป่วย</td>
                  <td width="269" bgcolor="#E2E2E2">&nbsp;</td>
                </tr>
            </table>
              <table width="375" border="0" cellspacing="0" cellpadding="0">
                <tr>
                  <td>สาเหตุของการมารักษา</td>
                </tr>
              </table>
              <table width="375" border="0" cellspacing="0" cellpadding="0">
                <tr>
                  <td height="56"><table width="375" border="0" cellspacing="2" cellpadding="0">
                    <tr>
                      <td width="19" height="52" valign="top"><p><br />
                        </p></td>
                      <td width="350" valign="top"><input type="checkbox" name="c1" id="c1" />
                        <label for="c1"></label>
                        โรคหลักของผู้ป่วย/อาการผิดปกติที่เกิดจากโรคหลัก<br />
                        <input type="checkbox" name="c2" id="c2" />
                        <label for="c2"></label>
                        โรคร่วม อาการผิดปกติอื่นๆ</td>
                    </tr>
                  </table></td>
                </tr>
              </table>
              <table width="375" border="0" cellspacing="2" cellpadding="0">
                <tr>
                  <td width="371" height="59" valign="top" bgcolor="#E2E2E2">บันทีกข้อมูล:</td>
                </tr>
            </table>
              <table width="375" border="0" cellspacing="0" cellpadding="0">
                <tr>
                  <td width="375" height="56"><table width="375" border="0" cellspacing="2" cellpadding="0">
                    <tr>
                      <td width="122" align="center" valign="top" bgcolor="#CCCCCC">CTRL</td>
                      <td width="121" align="center" valign="top" bgcolor="#CCCCCC">PT</td>
                      <td width="124" align="center" valign="top" bgcolor="#CCCCCC">INR</td>
                    </tr>
                    <tr>
                      <td align="center" valign="top" bgcolor="#DDDDFF">&nbsp;</td>
                      <td align="center" valign="top" bgcolor="#DDDDFF">&nbsp;</td>
                      <td align="center" valign="top" bgcolor="#DDDDFF">&nbsp;</td>
                    </tr>
                  </table></td>
                </tr>
            </table>
              <table width="373" border="0" cellspacing="0" cellpadding="0">
                <tr>
                  <td width="373"><table width="375" border="0" cellspacing="2" cellpadding="0">
                    <tr>
                      <td width="51" align="center" valign="middle" bgcolor="#CC0000">อา</td>
                      <td width="51" align="center" valign="middle" bgcolor="#CC0000">จ</td>
                      <td width="51" align="center" valign="middle" bgcolor="#CC0000">อ</td>
                      <td width="51" align="center" valign="middle" bgcolor="#CC0000">พ</td>
                      <td width="51" align="center" valign="middle" bgcolor="#CC0000">พฤ</td>
                      <td width="51" align="center" valign="middle" bgcolor="#CC0000">ศ</td>
                      <td width="51" align="center" valign="middle" bgcolor="#CC0000">ส</td>
                    </tr>
                    <tr>
                      <td align="center" valign="middle" bgcolor="#FFEAEA">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#FFEAEA">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#FFEAEA">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#FFEAEA">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#FFEAEA">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#FFEAEA">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#FFEAEA">&nbsp;</td>
                    </tr>
                  </table></td>
                </tr>
            </table>
              <table width="375" border="0" cellspacing="2" cellpadding="0">
                <tr>
                  <td width="251" align="right">From Last Visit</td>
                  <td width="118" align="right">cancle_btn</td>
                </tr>
            </table>
              <table width="375" border="0" cellspacing="2" cellpadding="0">
                <tr>
                  <td width="18" height="23">&nbsp;</td>
                  <td width="130" align="left">Weekly Dose ครั้งนี้ </td>
                  <td width="144"><label for="D1"></label>
                  <input type="text" name="D1" id="D1" /></td>
                  <td width="73">mg</td>
                </tr>
            </table>
              <table width="375" border="0" cellspacing="2" cellpadding="0">
                <tr>
                  <td width="18" height="23">&nbsp;</td>
                  <td width="130" align="left">Weekly Dose ครั้งก่อน </td>
                  <td width="144"><label for="D1"></label>
                    <input type="text" name="D2" id="D1" /></td>
                  <td width="73">mg</td>
                </tr>
            </table>
              <table width="375" border="0" cellspacing="2" cellpadding="0">
                <tr>
                  <td width="18" height="23">&nbsp;</td>
                  <td width="131" align="left">ร้อยละขนาดยาที่ปรับ</td>
                  <td width="144"><label for="D1"></label>
                    <input type="text" name="D3" id="D1" /></td>
                  <td width="72">%</td>
                </tr>
            </table>
              <table width="375" border="0" cellspacing="0" cellpadding="0">
                <tr>
                  <td>สรุปกิจกรรมที่ปฏิบัติ</td>
                </tr>
              </table>
              <table width="375" height="27" border="0" cellpadding="0" cellspacing="0">
                <tr>
                  <td width="208" height="27" valign="top"><table width="208" border="0" cellspacing="0" cellpadding="0">
                    <tr>
                      <td width="204" height="27"><input type="checkbox" name="d" id="d" />
ปรับขนาดยา<br />
<input type="checkbox" name="d" id="d2" />
<label for="d2"></label>
ให้ความรู้ ทบทวนอย่างละเอียด<br />
<input type="checkbox" name="d" id="d3" />
<label for="d3"></label>
ประเมินความรู้ ความเข้าใจเกี่ยวกับยา</td>
                    </tr>
                  </table></td>
                  <td width="167" valign="top"><table width="159" border="0" cellspacing="0" cellpadding="0">
                    <tr>
                      <td><input type="checkbox" name="d5" id="d5" />
ปรึกษาปัญหาร่วมกับแพทย์</td>
                    </tr>
                  </table></td>
                </tr>
              </table>
              <table width="297" height="40" border="0" cellpadding="0" cellspacing="5">
                <tr>
                  <td width="158" height="30">&nbsp;</td>
                  <td width="124">&nbsp;</td>
                </tr>
            </table></td>
            <td width="294" valign="top"><table width="289" border="0" cellspacing="0" cellpadding="0">
              <tr>
                <td align="right" bgcolor="#CCCCCC">Recall </td>
              </tr>
            </table>
              <table width="289" height="178" border="1" cellpadding="0" cellspacing="0">
                <tr>
                  <td width="285" height="176">&nbsp;</td>
                </tr>
            </table>
              <table width="289" height="180" border="0" cellpadding="0" cellspacing="0">
                <tr>
                  <td width="285" height="180" valign="top"><table width="291" border="0" cellspacing="1" cellpadding="0">
                    <tr>
                      <td width="60" align="center" valign="middle" bgcolor="#CCCCCC">วันที่</td>
                      <td width="45" align="center" valign="middle" bgcolor="#CCCCCC">CTRL</td>
                      <td width="45" align="center" valign="middle" bgcolor="#CCCCCC">PT</td>
                      <td width="45" align="center" valign="middle" bgcolor="#CCCCCC">INR</td>
                      <td width="45" align="center" valign="middle" bgcolor="#CCCCCC">TWD</td>
                      <td width="44" align="center" valign="middle" bgcolor="#CCCCCC">%<br />
                        +/-</td>
                    </tr>
                    <tr>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                    </tr>
                    <tr>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                    </tr>
                    <tr>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                    </tr>
                    <tr>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#A4A4FF">&nbsp;</td>
                    </tr>
                    <tr>
                      <td height="26" align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                      <td align="center" valign="middle" bgcolor="#D5D5FF">&nbsp;</td>
                    </tr>
                  </table></td>
                </tr>
            </table>
              <table width="290" border="0" cellspacing="0" cellpadding="0">
                <tr>
                  <td width="290" height="36" valign="top"><table width="290" border="0" cellspacing="0" cellpadding="0">
                    <tr>
                      <td align="right" bgcolor="#CCCCCC">Other med </td>
                    </tr>
                  </table></td>
                </tr>
              </table>
              <table width="290" border="0" cellspacing="1" cellpadding="0">
                <tr>
                  <td width="59" bgcolor="#CCCCCC">&nbsp;</td>
                  <td width="37" bgcolor="#CCCCCC">&nbsp;</td>
                  <td width="37" bgcolor="#CCCCCC">&nbsp;</td>
                  <td width="37" bgcolor="#CCCCCC">&nbsp;</td>
                  <td width="37" bgcolor="#CCCCCC">&nbsp;</td>
                  <td width="37" bgcolor="#CCCCCC">&nbsp;</td>
                  <td width="38" bgcolor="#CCCCCC">&nbsp;</td>
                </tr>
                <tr>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                </tr>
                <tr>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                </tr>
                <tr>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
                </tr>
                <tr>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
                  <td bgcolor="#DDDDFF">&nbsp;</td>
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                  <td bgcolor="#E1E1E1">&nbsp;</td>
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                  <td bgcolor="#E1E1E1">&nbsp;</td>
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                  <td bgcolor="#E1E1E1">&nbsp;</td>
                  <td bgcolor="#E1E1E1">&nbsp;</td>
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